ADULT OPEN HEART SURGICAL PROCEDURES DATA …



ADULT/PEDIATRIC OPEN-HEART SURGERY SERVICES

MIDB DATA RELEASE AUTHORIZATION AND VERIFICATION FORM

Michigan Department of Health and Human Services

Certificate of Need

| AUTHORITY: PA 368 of 1978, as amended |The Department of Health and Human Services is an equal opportunity employer, |

|COMPLETION: Is voluntary, but is required to obtain a |services and programs provider. |

|Certificate of Need. If not completed, a | |

|Certificate of Need will not be issued. | |

IMPORTANT: This form must be completed for each hospital allocating data.

|Name of Hospital |

|      |

|CON Number |Number of Open-Heart Procedures Allocated to this CON |

|      |      Adult       Pediatric |

|Is this hospital currently admitting patients on a regular basis? |Does this hospital intend to continue admitting patients on a regular basis? |

|NO YES |NO YES |

|Has this hospital previously committed MIDB data to another CON? |If YES, indicate the CON number(s) below and the date on which each approved |

|NO YES ( |open-heart service became operational. |

|CON Number |Date Open Heart Service Initiated |CON Number |Date Open Heart Service Initiated |

|      |      |      |      |

|Appendix A |Reported |Utilization |Projected |

|Adult - Major ICD-9-CM Code Group |Discharges |Weights |Open Heart |

|(See Appendix D for ICD-10 CM Codes) | | |Procedures |

|Principal Diagnosis | | | |

|A |394-397.9; 421-421.9; 424-424.99 |Valves |      |.459770 |      |

|B |441.01, 441.03, 441.1, 441.2, 441.6, 441.7 |Aortic Aneurysm |      |.611877 |      |

|C |745-747.99 |Congenital Anomalies |      |.475382 |      |

|D |414-414.99 |Other Chronic Ischemic |      |.462266 |      |

|E |410-410.99 |Acute Myocardial Infarct |      |.111867 |      |

|F |212.7, 398–398.99, 411–411.99, 423–423.9, |All Other Heart Conditions |      |.018210 |      |

| |425–425.9, 427–427.9, 428–428.9, 901–901.9, | | | | |

| |996.02, 996.03 | | | | |

|Non-Principal Diagnosis | |

|A |745-747.99 |Congenital Anomalies |      |.039305 |      |

|B |441.01, 441.03, 441.1, 441.2, 441.6, 441.7 |Aortic Aneurysm |      |.036191 |      |

|C |410-410.99 |Acute Myocardial Infarct |      |.035215 |      |

|D |394-397.9; 421-421.9; 424-424.99 |Valves |      |.024900 |      |

|E |414-414.99 |Other Chronic Ischemic |      |.011049 |      |

|F |212.7, 398–398.99, 411–411.99, 423–423.9, |All Other Heart Conditions |      |.016486 |      |

| |425–425.9, 427–427.9, 428–428.9, 901–901.9, | | | | |

| |996.02, 996.03 | | | | |

|ADULT TOTALS: |      | |      |

|APPENDIX B |Reported |Utilization |Projected |

|Pediatric - Major ICD-9-CM Code Group |Discharges |Weights |Open Heart |

|(See Appendix E for ICD-10 CM Codes) | | |Procedures |

| |745.0 - 747.99 |Congenital anomalies |      |.158111 |      |

| |164.1, 212.7, 390–429.99, 441.01, 441.03, 441.1,|All Other Heart Conditions |      |.030543 |      |

| |441.2, 441.6, 441.7, 785.51, 786.5-786.59, | | | | |

| |901.0–901.9, 996.02 | | | | |

|TOTALS: |      | |      |

Source: Calculated based on the 2017 Michigan Inpatient Data Base

Amended and Effective October 1, 2019

| APPENDIX C |

|ICD-9-CM TO ICD-10-CM CODE TRANSLATION FOR CONGENITAL HEART DISEASE |

|ICD-9 CODE |DESCRIPTION |ICD-10 CODE |DESCRIPTION |

|745.0 - 747.99 |Congenital Heart Disease |P 29.3 |Persistent Fetal Circulation |

| | |Q 20.0-Q 28.9 |Congenital Malformations of the |

| | | |Circulatory System |

"ICD-9-CM Code" means the disease codes and nomenclature found in the International Classification of Diseases - 9TH Revision - Clinical Modification, prepared by the Commission on Professional and Hospital Activities for The U.S. National Center for Health Statistics.

"ICD-10-CM Code" means the disease codes and nomenclature found in the International Classification of Diseases - 10th Revision - Clinical Modification, National Center for Health Statistics.

Notes:

• Proof of MHA verification of the MIDB data utilized above is required.

• MIDB data is committed for seven (7) years. Any previously committed hospital data will be accounted for in the Department’s analysis in accordance with the applicable standards, and only the increase in MIDB data, if any, from previous commitments will be counted.

• Submission of this form is an acknowledgement by the authorized agent for this application that the committing hospital has provided prior authorization to utilize the specified MIDB data above.

APPENDIX D (ICD-9-CM to ICD-10-CM CODE TRANSLATION FOR APPENDIX A)

|ICD-9 CM Code |Description |ICD-10 CM Code |Description |

|394 – 397.9 |Valves |I05.0-I08.9 |Rheumatic valve diseases |

| | |I09.0-I09.89 |Other rheumatic heart diseases |

|421 – 421.9 |Valves |A01.02 |Typhoid fever with heart involvement |

| | |I33.0-I33.9 |Acute and subacute endocarditis |

| | |I39 |Endocarditis and heart valve disorders in diseases classified elsewhere |

|424 – 424.99 |Valves |A18.84 |Tuberculosis of heart |

| | |I34.0-I37.9 |Nonrheumatic valve disorders |

| | |I38 |Endocarditis, valve unspecified |

| | |I39 |Endocarditis and heart valve disorders in diseases classified elsewhere |

| | |I42.0-I43 |Cardiomyopathies |

| | |M32.11 |Endocarditis in systemic lupus erythematosus |

|441.01,441.03 |Aortic Aneurysm |I71.01, I71.03 |Dissection of thoracic/thoracoabdominal aorta |

|441.1, 441.2 |Aortic Aneurysm |I71.1, I71.2 |Thoracic aortic aneurysm, ruptured/without rupture |

|441.6, 441.7 |Aortic Aneurysm |I71.5, I71.6 |Thoracoabdominal aortic aneurysm, ruptured/without rupture |

|745 – 747.99 |Congenital Anomalies |P29.3 |Persistent fetal circulation |

| | |Q20.0-Q28.9 |Congenital malformations of the circulatory system |

|414 – 414.99 |Other Chronic Ischemic |I25.10-I25.9 |Chronic ischemic heart disease |

| | |(excluding I25.2 old MI) | |

|410 – 410.99 |Acute Myocardial Infarct |I21.01-I22.9 |STEMI and NSTEMI MI |

|212.7 |All Other Heart Conditions |D15.1 |Benign neoplasm of heart |

|398 – 398.99 |All Other Heart Conditions |I09.0 |Rheumatic myocarditis |

| | |I09.81-I09.9 |Other/unspecified rheumatic heart diseases |

|411 – 411.99 |All Other Heart Conditions |I20.0 |Unstable angina |

| | |I24.0-I24.9 |Other acute ischemic heart disease |

| | |I25.110, I25.700, I25.710, |Atherosclerosis with unstable angina pectoris |

| | |I25.720, I25.730, I25.750, | |

| | |I25.760, I25.790 | |

|423 – 423.9 |All Other Heart Conditions |I31.0-I31.9 |Other diseases of pericardium |

|425 – 425.9 |All Other Heart Conditions |A18.84 |Tuberculosis of heart |

| |

|APPENDIX D – continued |

|ICD-9 CM Code |Description |ICD-10 CM Code |Description |

|425 – 425.9-Cont. |All Other Heart Conditions |I42.0-I43 |Cardiomyopathies |

|427 – 427.9 |All Other Heart Conditions |I46.2-I46.9 |Cardiac arrest |

| | |I47.0-I47.9 |Paroxysmal tachycardia |

| | |I48.0-I48.92 |Atrial fibrillation and flutter |

| | |I49.01-I49.9 |Other cardiac arrhythmias |

| | |R00.1 |Bradycardia, unspecified |

|428 – 428.9 |All Other Heart Conditions |I50.1-I50.9 |Heart failure |

|901 – 901.9 |All Other Heart Conditions |S25.00XA |Unspecified injury of thoracic aorta, initial encounter |

| | |S25.01XA |Minor laceration of thoracic aorta, initial encounter |

| | |S25.02XA |Major laceration of thoracic aorta, initial encounter |

| | |S25.09XA |Other specified injury of thoracic aorta, initial encounter |

| | |S25.101A |Unspecified injury of right innominate or subclavian artery, initial encounter |

| | |S25.102A |Unspecified injury of left innominate or subclavian artery, initial encounter |

| | |S25.109A |Unspecified injury of unspecified innominate or subclavian artery, initial encounter |

| | |S25.111A |Minor laceration of right innominate or subclavian artery, initial encounter |

| | |S25.112A |Minor laceration of left innominate or subclavian artery, initial encounter |

| | |S25.119A |Minor laceration of unspecified innominate or subclavian artery, initial encounter |

| | |S25.121A |Major laceration of right innominate or subclavian artery, initial encounter |

| | |S25.122A |Major laceration of left innominate or subclavian artery, initial encounter |

| | |S25.129A |Major laceration of unspecified innominate or subclavian artery, initial encounter |

| | |S25.191A |Other specified injury of right innominate or subclavian artery, initial encounter |

| | |S25.192A |Other specified injury of left innominate or subclavian artery, initial encounter |

| | |S25.199A |Other specified injury of unspecified innominate or subclavian artery, initial encounter |

| | |S25.20XA |Unspecified injury of superior vena cava, initial encounter |

| | |S25.21XA |Minor laceration of superior vena cava, initial encounter |

| | |S25.22XA |Major laceration of superior vena cava, initial encounter |

| | |S25.29XA |Other specified injury of superior vena cava, initial encounter |

| |

| |

|APPENDIX D – continued |

|ICD-9 CM Code |Description |ICD-10 CM Code |Description |

|901-901.9 Continued |All Other Heart Conditions |S25.301A |Unspecified injury of right innominate or subclavian vein, initial encounter |

| | |S25.302A |Unspecified injury of left innominate or subclavian vein, initial encounter |

| | |S25.309A |Unspecified injury of unspecified innominate or subclavian vein, initial encounter |

| | |S25.311A |Minor laceration of right innominate or subclavian vein, initial encounter |

| | |S25.312A |Minor laceration of left innominate or subclavian vein, initial encounter |

| | |S25.319A |Minor laceration of unspecified innominate or subclavian vein, initial encounter |

| | |S25.321A |Major laceration of right innominate or subclavian vein, initial encounter |

| | |S25.322A |Major laceration of left innominate or subclavian vein, initial encounter |

| | |S25.329A |Major laceration of unspecified innominate or subclavian vein, initial encounter |

| | |S25.391A |Other specified injury of right innominate or subclavian vein, initial encounter |

| | |S25.392A |Other specified injury of left innominate or subclavian vein, initial encounter |

| | |S25.399A |Other specified injury of unspecified innominate or subclavian vein, initial encounter |

| | |S25.401A |Unspecified injury of right pulmonary blood vessels, initial encounter |

| | |S25.402A |Unspecified injury of left pulmonary blood vessels, initial encounter |

| | |S25.409A |Unspecified injury of unspecified pulmonary blood vessels, initial encounter |

| | |S25.411A |Minor laceration of right pulmonary blood vessels, initial encounter |

| | |S25.412A |Minor laceration of left pulmonary blood vessels, initial encounter |

| | |S25.419A |Minor laceration of unspecified pulmonary blood vessels, initial encounter |

| | |S25.421A |Major laceration of right pulmonary blood vessels, initial encounter |

| | |S25.422A |Major laceration of left pulmonary blood vessels, initial encounter |

| | |S25.429A |Major laceration of unspecified pulmonary blood vessels, initial encounter |

| | |S25.491A |Other specified injury of right pulmonary blood vessels, initial encounter |

| | |S25.492A |Other specified injury of left pulmonary blood vessels, initial encounter |

| | |S25.499A |Other specified injury of unspecified pulmonary blood vessels, initial encounter |

| | |S25.501A |Unspecified injury of intercostal blood vessels, right side, initial encounter |

| | |S25.502A |Unspecified injury of intercostal blood vessels, left side, initial encounter |

| | |S25.509A |Unspecified injury of intercostal blood vessels, unspecified side, initial encounter |

| | |S25.502A |Unspecified injury of intercostal blood vessels, left side, initial encounter |

| | | | |

|APPENDIX D – continued | | | |

|ICD-9 CM Code |Description |ICD-10 CM Code |Description |

|901-901.9 Continued |All Other Heart Conditions |S25.511A |Laceration of intercostal blood vessels, right side, initial encounter |

| | |S25.512A |Laceration of intercostal blood vessels, left side, initial encounter |

| | |S25.519A |Laceration of intercostal blood vessels, unspecified side, initial encounter |

| | |S25.591A |Other specified injury of intercostal blood vessels, right side, initial encounter |

| | |S25.592A |Other specified injury of intercostal blood vessels, left side, initial encounter |

| | |S25.599A |Other specified injury of intercostal blood vessels, unspecified side, initial encounter |

| | |S25.801A |Unspecified injury of other blood vessels of thorax, right side, initial encounter |

| | |S25.802A |Unspecified injury of other blood vessels of thorax, left side, initial encounter |

| | |S25.809A |Unspecified injury of other blood vessels of thorax, unspecified side, initial encounter |

| | |S25.811A |Laceration of other blood vessels of thorax, right side, initial encounter |

| | |S25.812A |Laceration of other blood vessels of thorax, left side, initial encounter |

| | |S25.819A |Laceration of other blood vessels of thorax, unspecified side, initial encounter |

| | |S25.891A |Other specified injury of other blood vessels of thorax, right side, initial encounter |

| | |S25.892A |Other specified injury of other blood vessels of thorax, left side, initial encounter |

| | |S25.899A |Other specified injury of other blood vessels of thorax, unspecified side, initial encounter |

| | |S25.90XA |Unspecified injury of unspecified blood vessel of thorax, initial encounter |

| | |S25.91XA |Laceration of unspecified blood vessel of thorax, initial encounter |

| | |S25.99XA |Other specified injury of unspecified blood vessel of thorax, initial encounter |

|996.02, 996.03 |All Other Heart Conditions |T82.01XA |Breakdown (mechanical) of heart valve prosthesis, initial encounter |

| | |T82.02XA |Displacement of heart valve prosthesis, initial encounter |

| | |T82.03XA |Leakage of heart valve prosthesis, initial encounter |

| | |T82.09XA |Other mechanical complication of heart valve prosthesis, initial encounter |

| | |T82.211A |Breakdown (mechanical) of coronary artery bypass graft, initial encounter |

| | |T82.212A |Displacement of coronary artery bypass graft, initial encounter |

| | |T82.213A |Leakage of coronary artery bypass graft, initial encounter |

| | |T82.218A |Other mechanical complication of coronary artery bypass graft, initial encounter |

| |

APPENDIX E (ICD-9-CM TO ICD-10-CM CODE TRANSLATION FOR APPENDIX B)

|ICD-9 CM Code |Description |ICD-10 CM Code |Description |

|745.0 – 747.99 |Congenital Anomalies |P29.3 |Persistent fetal circulation |

| | |Q20.0-Q28.9 |Congenital malformations of the circulatory system |

|164.1 |All Other Heart Conditions |C38.0 |Malignant neoplasm of heart |

| | |C45.2 |Mesothelioma of pericardium |

|212.7 |All Other Heart Conditions |D15.1 |Benign neoplasm of heart |

|390 - 429.99 |All Other Heart Conditions |A01.02 |Typhoid fever with heart involvement |

| | |A18.84 |Tuberculosis of heart |

| | |I00-I09.9 |Rheumatic fever/heart diseases |

| | |I10-I15.9 |Hypertensive diseases |

| | |I20.0-I25.9 |Ischemic heart diseases |

| | |I26.01-I28.9 |Pulmonary heart disease/pulmonary circulation diseases |

| | |I30.0-I52 |Other forms of heart disease |

| | |I97.0-197.191 |Intraoperative/postprocedural cardiac complications |

| | |N26.2 |Page kidney |

| | |R00.1 |Bradycardia, unspecified |

| | |T80.0XXA |Air embolism following infusion, transfusion and therapeutic injection, initial encounter |

| | |T81.718A |Complication of other artery following a procedure, not elsewhere classified, initial encounter |

| | |T81.72XA |Complication of vein following a procedure, not elsewhere classified, initial encounter |

| | |T82.817A |Embolism of cardiac prosthetic devices, implants and grafts, initial encounter |

| | |T82.818A |Embolism of vascular prosthetic devices, implants and grafts, initial encounter |

|441.01 |All Other Heart Conditions |I71.01 |Dissection of thoracic aorta |

|441.03 |All Other Heart Conditions |I71.03 |Dissection of thoracoabdominal aorta |

|441.1 |All Other Heart Conditions |I71.1 |Thoracic aortic aneurysm, ruptured |

| | | | |

|APPENDIX E-Continued |

|ICD-9 CM Code |Description |ICD-10 CM Code |Description |

|441.2 |All Other Heart Conditions |I71.2 |Thoracic aortic aneurysm, without rupture |

|441.6 |All Other Heart Conditions |I71.5 |Thoracoabdominal aortic aneurysm, ruptured |

|441.7 |All Other Heart Conditions |I71.6 |Thoracoabdominal aortic aneurysm, without rupture |

|785.51 |All Other Heart Conditions |R57.0 |Cardiogenic shock |

|786.5-786.59 |All Other Heart Conditions |R07.1-R07.9 |Chest pain |

|901.0 – 901.9 |All Other Heart Conditions |S25.00XA |Unspecified injury of thoracic aorta, initial encounter |

| | |S25.01XA |Minor laceration of thoracic aorta, initial encounter |

| | |S25.02XA |Major laceration of thoracic aorta, initial encounter |

| | |S25.09XA |Other specified injury of thoracic aorta, initial encounter |

| | |S25.101A |Unspecified injury of right innominate or subclavian artery, initial encounter |

| | |S25.102A |Unspecified injury of left innominate or subclavian artery, initial encounter |

| | |S25.109A |Unspecified injury of unspecified innominate or subclavian artery, initial encounter |

| | |S25.111A |Minor laceration of right innominate or subclavian artery, initial encounter |

| | |S25.112A |Minor laceration of left innominate or subclavian artery, initial encounter |

| | |S25.119A |Minor laceration of unspecified innominate or subclavian artery, initial encounter |

| | |S25.121A |Major laceration of right innominate or subclavian artery, initial encounter |

| | |S25.122A |Major laceration of left innominate or subclavian artery, initial encounter |

| | |S25.129A |Major laceration of unspecified innominate or subclavian artery, initial encounter |

| | |S25.191A |Other specified injury of right innominate or subclavian artery, initial encounter |

| | |S25.192A |Other specified injury of left innominate or subclavian artery, initial encounter |

| | |S25.199A |Other specified injury of unspecified innominate or subclavian artery, initial encounter |

| | |S25.20XA |Unspecified injury of superior vena cava, initial encounter |

| | |S25.21XA |Minor laceration of superior vena cava, initial encounter |

| | |S25.22XA |Major laceration of superior vena cava, initial encounter |

| | |S25.29XA |Other specified injury of superior vena cava, initial encounter |

| | |S25.301A |Unspecified injury of right innominate or subclavian vein, initial encounter |

|APPENDIX E - continued |

|ICD-9 CM Code |Description |ICD-10 CM Code |Description |

|901.0 – 901.9-Continued |All Other Heart Conditions |S25.302A |Unspecified injury of left innominate or subclavian vein, initial encounter |

| | |S25.309A |Unspecified injury of unspecified innominate or subclavian vein, initial encounter |

| | |S25.311A |Minor laceration of right innominate or subclavian vein, initial encounter |

| | |S25.312A |Minor laceration of left innominate or subclavian vein, initial encounter |

| | |S25.319A |Minor laceration of unspecified innominate or subclavian vein, initial encounter |

| | |S25.321A |Major laceration of right innominate or subclavian vein, initial encounter |

| | |S25.322A |Major laceration of left innominate or subclavian vein, initial encounter |

| | |S25.329A |Major laceration of unspecified innominate or subclavian vein, initial encounter |

| | |S25.391A |Other specified injury of right innominate or subclavian vein, initial encounter |

| | |S25.392A |Other specified injury of left innominate or subclavian vein, initial encounter |

| | |S25.399A |Other specified injury of unspecified innominate or subclavian vein, initial encounter |

| | |S25.401A |Unspecified injury of right pulmonary blood vessels, initial encounter |

| | |S25.402A |Unspecified injury of left pulmonary blood vessels, initial encounter |

| | |S25.409A |Unspecified injury of unspecified pulmonary blood vessels, initial encounter |

| | |S25.411A |Minor laceration of right pulmonary blood vessels, initial encounter |

| | |S25.412A |Minor laceration of left pulmonary blood vessels, initial encounter |

| | |S25.419A |Minor laceration of unspecified pulmonary blood vessels, initial encounter |

| | |S25.421A |Major laceration of right pulmonary blood vessels, initial encounter |

| | |S25.422A |Major laceration of left pulmonary blood vessels, initial encounter |

| | |S25.429A |Major laceration of unspecified pulmonary blood vessels, initial encounter |

| | |S25.491A |Other specified injury of right pulmonary blood vessels, initial encounter |

| | |S25.492A |Other specified injury of left pulmonary blood vessels, initial encounter |

| | |S25.499A |Other specified injury of unspecified pulmonary blood vessels, initial encounter |

| | |S25.501A |Unspecified injury of intercostal blood vessels, right side, initial encounter |

| | |S25.502A |Unspecified injury of intercostal blood vessels, left side, initial encounter |

| | |S25.509A |Unspecified injury of intercostal blood vessels, unspecified side, initial encounter |

| | |S25.511A |Laceration of intercostal blood vessels, right side, initial encounter |

| | |S25.512A |Laceration of intercostal blood vessels, left side, initial encounter |

| | |S25.519A |Laceration of intercostal blood vessels, unspecified side, initial encounter |

|APPENDIX E - continued |

|ICD-9 CM Code |Description |ICD-10 CM Code |Description |

|901.0 – 901.9-Continued |All Other Heart Conditions |S25.591A |Other specified injury of intercostal blood vessels, right side, initial encounter |

| | |S25.592A |Other specified injury of intercostal blood vessels, left side, initial encounter |

| | |S25.599A |Other specified injury of intercostal blood vessels, unspecified side, initial encounter |

| | |S25.801A |Unspecified injury of other blood vessels of thorax, right side, initial encounter |

| | |S25.802A |Unspecified injury of other blood vessels of thorax, left side, initial encounter |

| | |S25.809A |Unspecified injury of other blood vessels of thorax, unspecified side, initial encounter |

| | |S25.811A |Laceration of other blood vessels of thorax, right side, initial encounter |

| | |S25.812A |Laceration of other blood vessels of thorax, left side, initial encounter |

| | |S25.819A |Laceration of other blood vessels of thorax, unspecified side, initial encounter |

| | |S25.891A |Other specified injury of other blood vessels of thorax, right side, initial encounter |

| | |S25.892A |Other specified injury of other blood vessels of thorax, left side, initial encounter |

| | |S25.899A |Other specified injury of other blood vessels of thorax, unspecified side, initial encounter |

| | |S25.90XA |Unspecified injury of unspecified blood vessel of thorax, initial encounter |

| | |S25.91XA |Laceration of unspecified blood vessel of thorax, initial encounter |

| | |S25.99XA |Other specified injury of unspecified blood vessel of thorax, initial encounter |

|996.02 |All Other Heart Conditions |T82.01XA |Breakdown (mechanical) of heart valve prosthesis, initial encounter |

| | |T82.02XA |Displacement of heart valve prosthesis, initial encounter |

| | |T82.03XA |Leakage of heart valve prosthesis, initial encounter |

| | |T82.09XA |Other mechanical complication of heart valve prosthesis, initial encounter |

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